Evidence-Based Reviews

Premenstrual dysphoric disorder: How to alleviate her suffering

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Accurate diagnosis, tailored treatments can greatly improve women’s quality of life


 

References

Approximately 75% of women experience a premenstrual change in emotional or physical symptoms commonly referred to as premenstrual syndrome (PMS). These symptoms—including increased irritability, tension, depressed mood, and somatic complaints such as breast tenderness and bloating—often are mild to moderate and cause minimal distress.1 However, approximately 3% to 9% of women experience moderate to severe premenstrual mood symptoms that meet criteria for premenstrual dysphoric disorder (PMDD).2

PMDD includes depressed or labile mood, anxiety, irritability, anger, insomnia, difficulty concentrating, and other symptoms that occur exclusively during the 2 weeks before menses and cause significant deterioration in daily functioning. Women with PMDD use general and mental health services more often than women without the condition.3 They may experience impairment in marital and parental relationships as severe as that experienced by women with recurrent or chronic major depression.2

PMDD often responds to treatment. Unfortunately, many women with PMDD do not seek treatment, and up to 90% may go undiagnosed.4 In this article, we review the prevalence, etiology, diagnosis, and treatment of PMDD.

A complex disorder

A distinguishing characteristic of PMDD is the timing of symptom onset. In women with PMDD, mood symptoms occur only during the luteal phase of the menstrual cycle (ovulation until onset of menses) and resolve after menstruation onset. Women with PMDD report normal mood and functioning during the follicular phase of the menstrual cycle (first day of the menstrual cycle until ovulation).

Although PMS and PMDD criteria share affective and somatic symptoms, more symptoms are required for a PMDD diagnosis, and symptoms often are more severe.5 As defined in DSM-IV-TR (Table),6 PMDD has a broader range of symptoms than PMS and includes symptoms not included in the American College of Obstetrics and Gynecology criteria for PMS,7 such as impaired concentration, appetite, and sleep (hypersomnia or insomnia); and mood lability. PMDD symptoms must occur only during the 2 weeks preceding menses, although on average symptoms last 6 days and severity usually peaks in the 2 days before menses.1 The prevalence of subthreshold PMDD is fairly common; approximately 19% of women will meet some—but not all—DSM-IV-TR criteria for PMDD.3

In a revision proposed for DSM-5, PMDD would be included as a mood disorder, which represents a significant change from DSM-IV-TR, where it is listed in the appendix as “research criteria.”8 In addition, in oral contraceptive users, a PMDD diagnosis should not be made unless the premenstrual symptoms are reported to be present and as severe when the woman is not taking the oral contraceptive.8

Comorbidity with other axis I disorders such as major depressive disorder (MDD), bipolar disorder (BD), and anxiety disorders is high.9-11 Women with an MDD history have the highest correlation with PMDD,9 and worsening premenstrual mood symptoms are more common in women with BD.12 Payne et al11 found that premenstrual symptoms were reported by twice as many women diagnosed with mood disorders (68%) than women without a psychiatric diagnosis (34%). Moreover, 38% to 46% of women with PMDD have comorbid seasonal affective disorder, and 11% to 38% report a comorbid anxiety disorder.12 Women with PMDD and a history of MDD have lower cortisol concentrations than non-PMDD women.10 Although interventions for PMDD and a comorbid axis I disorder may be similar, it is important to consider both when planning treatment.

Abuse, trauma, and PMDD. An association between PMS/PMDD and a history of sexual and physical abuse is well-documented.13 Studies have reported abuse histories among almost 60% of women with PMDD,14 although studies comparing abuse and trauma in PMDD vs non-PMDD women have been small. A recent study found that trauma and posttraumatic stress disorder are independently associated with PMDD and premenstrual symptoms.15

Evidence suggests that a history of abuse is associated with specific biological sequelae in PMDD women, particularly with respect to hypothalamic-pituitary-thyroid axis measures and noradrenergic activity.16-18 Women with PMDD and a history of sexual abuse show:

  • markedly elevated triiodothyronine (T3) concentrations (the more biologically potent thyroid hormone) that appear to result from increased conversion of thyroxine (T4) to T316
  • lower circulating plasma norepinephrine concentrations17
  • greater resting and stress-induced heart rates and systolic blood pressure compared with non-abused PMDD women, an effect that is eliminated by clonidine (an α-2 adrenergic receptor agonist).18

One study showed that PMDD women with abuse histories had higher blood pressure measurements at rest and during stress and exhibited greater vascular tone than non-abused women; these effects were not seen in non-PMDD women with similar abuse histories.14 This body of evidence is consistent with the concept that PMDD is a stress-related disorder,19 and that a history of abuse is prevalent and may identify a clinically distinct subgroup of PMDD women with respect to thyroid axis and adrenergic physiology. Screening PMDD patients for abuse histories may help manage the disorder.

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